Basic Information
| Provider Information | |||||||||
| NPI: | 1164897112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONIE | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | |||||||||
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| Credential: | AGNP, ARNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34503 9TH AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538358700 | ||||||||
| FaxNumber: | 2538358755 | ||||||||
| Practice Location | |||||||||
| Address1: | 34503 9TH AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538358700 | ||||||||
| FaxNumber: | 2538358755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2015 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | AP60616117 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LG0600X | AP60616117 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | AP60616117 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 2050385 | 05 | WA | MEDICAID |